Abstract
Background
Communication skills required for doctors do not consist of simple uses of particular linguistic forms but include uses that are sensitive to the interactional context. In consultations where the doctors have pre‐existing information about their patients, this can complicate the context of problem solicitation. We investigated how doctors tailor opening questions to a context in which they get pre‐existing information from a medical questionnaire (MQ) filled out by the patients.
Methods
The data for this study were 87 video recordings of first visits to the department of general medicine at a university hospital in Japan. We qualitatively analyzed doctors' practices in problem solicitation in an opening phase using conversation analysis and triangulated it with quantitative analysis.
Results
Open‐ended questions accounted for 26.4% of opening questions. Among the closed‐ended questions, 75.0% were confirming questions about symptoms. In cases with open‐ended questions, doctors minimized the relevance of the MQ to problem solicitation by giving license to repeat the description from the MQ. In cases with closed‐ended questions, doctors highlighted the relevance of the MQ by sharing the MQ. Through these practices, they avoided patients' possible confusion about problem presentation while simultaneously maximizing the possibility of soliciting the patients' narratives.
Conclusions
Doctors adjusted the level of relevance of pre‐existing information to problem solicitation through both verbal and nonverbal management of the MQ. It will be useful to instruct such context‐dependent practices to improve communication skills in medical school curriculum.
Keywords: conversation analysis, general medicine, medical questionnaire, opening question, pre‐existing information, problem presentation
We investigated how doctors tailor opening questions to a context in which they get pre‐existing information from a medical questionnaire in first‐visit consultations in Japan. Open‐ended questions accounted for 26.4% of opening questions, while 75.0% of closed‐ended questions were confirming questions about symptoms. Doctors minimized the relevance of the MQ to problem solicitation in cases with open‐ended questions and highlighted it instead in cases with closed‐ended questions.
1. INTRODUCTION
The opening phase of a medical interview is the first and only one in which patients are allowed to describe their problems in their own words. 1 , 2 If the problems remain hidden earlier, patients sometimes disclose them during the closing phase. 3 Appropriate problem solicitation elicits a sufficient description and can reduce late‐arising problems during the interview. 4 For patient‐centered communication, an open‐ended question is strongly recommended as an opening question in the first visit of a medical consultation. 5 , 6 However, while the use of open‐ended questions was beneficial for gathering medical information from standardized patients, 7 , 8 that was not necessarily the case in real first visits. 9 Moreover, open‐ended questions have been reported problematic as opening questions in follow‐up visits. 10 Communication skills required for doctors do not consist of simple uses of particular linguistic forms; instead, they include uses that are sensitive to the interactional context. 11 These findings suggest that the type of opening question should be chosen according to the context.
Questions in general display levels of speakers' knowledge about the topic and solicit the recipients to respond accordingly. 12 For example, an appropriate answer to an open‐ended question may be to describe something, whereas just saying “yes” can be appropriate to a closed‐ended question. Heritage & Robinson empirically investigated the influence of opening questions on patients' problem presentations in video‐taped data of primary‐care visits. 13 They classified opening questions into five types: general inquiries (e.g., “How can I help you?”), gloss questions for confirmation (e.g., “Sounds like you're uncomfortable.”), confirming questions about symptoms (e.g., “You're having headache for a week.”), “How are you?” questions, and history‐taking questions. They found that general inquiries were predominant and elicited long problem presentations as well as patients' satisfaction. 14
They raised another point which is related to a conversational norm called “recipient's design”; a speaker should not say something that a recipient already knows. 15 If a doctor has knowledge of a patient's problem before the consultation, that may complicate an otherwise straightforward process of problem solicitation. If doctors start opening questions without acknowledging the already‐obtained information, patients cannot tell how much prior information is shared. Therefore, patients are likely to be confused about whether they should repeat the information. Although Heritage & Robinson have shown some cases in which doctors tailor the opening question to avoid the confusion, 13 the way to resolve such complicated contexts has not been fully investigated.
A medical questionnaire (MQ) is a tool for patients to convey their own information to a medical staff prior to the consultation. In the department of general medicine in Japan, the MQ has been reported to consist of 19.7 items on average: patient's chief complaint, social information (name, age, occupation), lifestyles, and so on. 16 Since doctors utilize the MQ in various ways during consultations, the variety may further complicate the context of problem presentations. In this study, we aim to investigate how doctors manage problem solicitation to avoid such confusion caused by the MQ in the opening phase of first‐visit consultations in Japan.
2. METHODS
2.1. Setting
The setting is a department of general medicine at a university hospital in Japan, which also provides primary care. 17 Figure 1 is the English‐translated MQ which is used in the department. Doctors <2 years are junior residents, and they examined patients under the supervision of senior doctors.
FIGURE 1.
The English‐translated medical questionnaire
2.2. Data collection
In accordance with the study protocol approved by the Institutional Review Board, 120 patients and 28 corresponding doctors were asked to participate in the study, and written informed consents were obtained from 97 patients (response rate, 80.8%) and 28 doctors. The data are 97 consultations that took place during patients' first visits to the department, which were video‐recorded from December 2015 to December 2019. To investigate the relation between the design of opening questions and patients' problem presentations, we excluded the following cases: general health check‐ups and others in which the patients' companions replied to the opening question before the patient and in which the patient started a problem presentation before completing an opening question. Our analysis resulted in focusing on 87 cases.
2.3. Data analysis
We triangulated qualitative analysis with quantitative analysis. The method of the qualitative study was conversation analysis. 18 This can clarify the interaction between participants in every moment through a detailed analysis using transcripts of actual conversational data. We analyzed the type of opening question, concomitant verbal and nonverbal practices about the MQ, and patients' problem presentations in the opening phase. Each utterance in the transcripts consists of two lines. The first line shows the original Japanese utterance with transcription conventions originally developed by Gail Jefferson. 19 The second line displays an idiomatic English translation. Symbols in the transcripts are listed below.
[word] overlapping utterances
(0.0) seconds of silence
: sound stretch
?/./, rising/falling/continuing intonation, respectively
<word> decrease in tempo
([word]) omitted elements in Japanese
The distribution of doctors' practices about the MQ for opening questions was quantitatively calculated. We used Fisher's exact test to compare instances of giving license to repeat information from the MQ and sharing the MQ between open‐ and closed‐ended question groups. A p‐value of <0.05 was considered statistically significant. Statistical analyses were performed using PASW Statistics 27.0 (IBM Corporation).
3. RESULTS
3.1. Data description
The data for this study included 87 patients and 28 doctors. The patients' ages ranged from 20 to 86 years old. The doctors' clinical experience ranged from less than a year to 34 years. Based on doctors' experience years, 87 cases were divided into three groups: <2 years (n = 22), between two and 10 years (n = 37), and more than 10 years (n = 28) (Table 1). As for the type of opening questions, general inquiries occupied 26.4%, and the most predominant question type was confirming questions about symptoms (55.2%). We grouped general inquiries and “How are you?” questions as open‐ended questions, and the rest as closed‐ended questions. The prevalence of open‐ended questions was as same as that of general inquiries, and 75.0% (48/64) of closed‐ended questions were confirming questions about symptoms. Doctors for more than 10 years tended to prefer closed‐ended questions.
TABLE 1.
Classification of opening questions in 87 first‐visit consultations in Japan (2015–2019)
| Question type | Group | Our results | Heritage & Robinson (2006) 13 | ||
|---|---|---|---|---|---|
| n (%) | |||||
| [Doctor's years of experience: <2/2–10/>10] | |||||
| General inquiry | Open Q | 23 (26.4) | 23 (26.4) [8/14/1] | 187 (61.9) | 203 (67.2) |
| “How are you?” question | 0 (0.0) | 16 (5.3) | |||
| Gloss question for confirmation | Closed Q | 11 (12.6) | 64 (73.6) [14/23/27] | 33 (10.9) | 99 (32.8) |
| Confirming question about symptoms | 48 (55.2) | 48 (15.9) | |||
| History‐taking question | 5 (5.8) | 18 (6.0) | |||
| Total | 87 (100) [22/37/28] | 302 (100) | |||
Abbreviations: Closed Q, closed‐ended question; n, number; Open Q, open‐ended question.
3.2. Qualitative analysis
All the four extracts start immediately after the doctor greets the patient. Extracts 1 and 2 are cases with open‐ended questions and Extracts 3 and 4 with closed‐ended questions.
3.2.1. Open‐ended question without any mention of the MQ
Extract 1 (Table 2) is an example in which a doctor used an open‐ended question to solicit a patient's problem presentation without mentioning the MQ and the patient was confused in describing his problem. The patient is a 76‐year‐old man and had written down “runny nose, sore throat, and cough for 3 days” as his chief complaint on the MQ.
TABLE 2.
Transcribed extracts from the opening phases in consultations
| Extract 1 [171225hori_cold] | |
| 01 DOC: | kyou donoyouna koto de korareta ka oshiete itadaite ii desu ka:? |
| Would you tell me what brings you here today? | |
| 02 | (0.5) |
| 03 PAT: | e:::: yousuruni (0.7) chotto kaze hiita: to omotte:, |
| Well, in short, I think I've got a cold, | |
| 04 DOC: | n:n. chotto itsu kara donna syoujou ga atta ka oshiete |
| 05 | moratte ii [desu ka?] |
| Yeah, would you tell me how long you have suffered and what sort of symptoms you have had? | |
| 06 PAT: | [mikka]yokka: gurai mae kara:: nn nodo ga itaku, |
| For about 3 or 4 days, uhm I've had a sore throat, | |
| Extract 2 [160314aki_zutsuu] | |
| 01 DOC: | monshinhyou yoma sashite moratta no to::, |
| I've read your medical questionnaire, and | |
| 02 | ato kako no karute toka mo misasite [moratte:,] |
| also checked your past medical chart, and | |
| 03 PAT: | [hai. Hai.] |
| Uh huh. | |
| 04 DOC: | joukyou tosite wa haaku wa shiteru tsumori nan desu [kedo:,] |
| I believe I understood the situation, but | |
| 05 PAT: | [hai.] |
| Uh huh. | |
| 06 DOC: | u:: mou ikkai kantanni de ee [node,] |
| uhm can you tell me | |
| 07 PAT: | [hai.] |
| Yes. | |
| 08 DOC: | e: dou itta koto okomari ka tte iu no o, |
| uhm what your trouble is, | |
| 09 PAT: | [hai.] |
| Uh huh. | |
| 10 DOC: | [ano:] oshiete itadaite ee desu [ka? |
| again just briefly? | |
| 11 PAT: | [a hai. |
| Um, yes. | |
| 12 | (0.3) |
| 13 | eto:: ma ano < kata kori:> |
| Uhm well uhm ([I've had]) a stiff shoulder | |
| 14 DOC: | e[:: e:.] |
| Uh huh. | |
| 15 PAT: | [ga ke]kkou hidoku te zutto atta n desu kedo::, |
| I've always had a quite bad one, and | |
| Extract 3 [161102mizu_furatsuki] | |
| 01 DOC: | furatsuki::: ga ikkagetu hodo mae kara:, |
| You have had dizziness for about a month. | |
| 02 PAT: | hai. |
| Yes. | |
| 03 | (1.1) |
| 04 DOC: | u:n |
| Um | |
| 05 | (2.0) |
| 06 | asa (.) me:sameta toki ni ooi n desu ka? |
| Does the dizziness often occur in the morning when you wake up? | |
| Extract 4 [171025yoko_appetite] | |
| 01 DOC: | kyou wa sankagetsu mae kara. |
| Today, for the past 3 months, | |
| 02 PAT: | sou desu ne:: etto <hachigatsu [atama]>:::, |
| Right, well around the beginning of August, | |
| 03 DOC: | [ee] hachigatsu atama. |
| Yes, around the beginning of August. | |
| 04 PAT: | gurai kara (1.2) e::tto::::: (0.3) a (0.8) mazu wa |
| 05 | shichigatsu no matsu gurai ni ikinari |
| Well, first, at the end of July, I suddenly experienced ([starts a narrative]) | |
Abbreviations: DOC, doctor; PAT, patient.
In line 01, the doctor uses a general inquiry, “Would you tell me what brings you here today?” without mentioning any information from the MQ while looking at the patient. This is hearable as soliciting the full description of the patient's problems as if the doctor had not obtained any information from the MQ. The patient may well be confused about whether he should repeat his problem written on the MQ. Indeed, he delays his answer with silence, and presents his candidate diagnosis, “I think I've got a cold,” rather than presenting his problem itself in lines 02–03. The doctor pursues a description of his symptoms explicitly in lines 04–05 (“Would you tell me how long you've suffered and what sort of symptoms you've had?”). The sentence structure of her second question is almost the same as that of her opening question. By issuing a similar question design twice, she is retrospectively making clear that her first question was intended to solicit a full description of his symptoms, including what is described in the MQ. In line 06, the patient immediately replies to the prior question.
3.2.2. Open‐ended question with a mention of the MQ
Extract 2 (Table 2) is a typical case in which an open‐ended question is accompanied by a mention of the MQ. The patient is a 41‐year‐old woman and had described a “terrible headache for 2 or 3 days” as her chief complaint on the MQ.
In lines 01–04, the doctor employs a preface acknowledging what he read on the MQ (“I've read your medical questionnaire”). Then, he starts an open‐ended question (lines 06–10) in which he specifically gives the patient a license to repeat information from the MQ (“Can you tell me what your trouble is, again?”). This verbal practice sets the patient free from recipient's design. As the response, the patient starts presenting her problem smoothly.
3.2.3. Closed‐ended question without sharing the MQ
In Extract 3 (Table 2), a doctor employs a closed‐ended question which fails to solicit the patient's narrative immediately. The patient is a 59‐year‐old woman and had written “I have felt dizziness for about a month, especially in the morning, when I get up” as her chief complaint on the MQ.
In line 01, the doctor attempts to solicit a problem presentation by using a confirmation question for the symptoms, “You have had dizziness for about a month.” This question is constructed by reusing descriptions from the MQ: the words “dizziness” and “for about a month.” In addition, the doctor glances at the MQ while holding it. These verbal and nonverbal practices demonstrate the doctor's having read the MQ. Thus, the patient is not confused about how to answer the question. However, because it is a closed‐ended question, the patient responds only with “yes” in line 02. The doctor waits for further description without success before and after registering the answer (line 03–05). To elicit further problem presentation, the doctor asks another confirming question about the symptoms written on the MQ, “Does the dizziness often occur in the morning when you wake up?” (line 06).
3.2.4. Closed‐ended question with sharing the MQ
In Extract 4 (Table 2), a doctor elicits patients' problem presentations successfully by sharing the MQ with patients. The patient is a 28‐year‐old woman and had listed “poor appetite, fatigue, unexpected anxiety, insomnia, and diarrhea for about 3 months” as her chief complaint on the MQ.
The doctor asks a confirming question about the symptoms using what is written on the MQ, “for the past 3 months” (line 01). While he asks this question, he nonverbally shares the MQ in following ways. First, he puts the MQ between the patient and himself, adjusting its angle so that both can look at it (Figure 2A). Next, coinciding with saying “for the past 3 months,” he points at the words written on the MQ (Figure 2B). With these practices, the doctor solicits the patient's gaze toward the MQ. Furthermore, the doctor encourages the patient to start her narrative by continuously pointing at the words, even after the patient confirms them in line 02. The patient starts her problem presentation by saying “around the beginning of August.”
FIGURE 2.
Line drawings before (A) and during (B) the opening question in extract 4. DOC, doctor; MQ, medical questionnaire; PAT, patient.
3.3. Quantitative analysis
Based on the qualitative analysis of the opening phase, we quantitatively showed a distributional difference in doctors' practices related to MQs between the open‐ and closed‐ended question groups (Table 3). A verbal practice just before opening questions was counted as giving license to repeat information from the MQ (e.g., “Can you tell me your problem again?”). Moreover, a nonverbal practice during opening questions was identified as sharing the MQ (e.g., “adjusting the MQ's angle” or “pointing at the MQ”). Most of open‐ended questions were accompanied by the verbal practice, and it was significantly more associated with open‐ended questions than with closed‐ended questions, whereas the nonverbal one was significantly more associated with closed‐ended questions. In cases with open‐ended questions, junior residents accounted for most of cases without the verbal practice. In cases with closed‐ended questions, doctors more than 10 years occupied more than half of cases with the nonverbal practice.
TABLE 3.
Doctor's practices linked with a medical questionnaire in each opening question
| Open Q | Closed Q | p | |
|---|---|---|---|
| n (%) | |||
| [Doctor's years of experience: <2/2–10/>10] | |||
| Verbal practice | |||
| Giving license to repeat | 16 (69.6) | 2 (3.1) | <0.001*** |
| information from MQ | [3/12/1] | [2/0/0] | |
| Nonverbal practice | |||
| Sharing MQ | 0 (0.0) | 20 (31.3) | <0.001*** |
| [0/0/0] | [3/5/12] | ||
| Total | 23 [8/14/1] | 64 [14/23/27] | |
Abbreviations: Closed Q, closed‐ended question; MQ, medical questionnaire; n, number; Open Q, open‐ended question.
p < 0.001.
4. DISCUSSION
This is the first empirical study to show how to tailor opening questions in first‐visit consultations in Japan. As opening questions, doctors used not only open‐ended questions but closed‐ended questions. For smooth problem presentation, more experienced doctors allowed patients to repeat description on the MQ in cases with open‐ended questions, while they shared the MQ in cases with closed‐ended questions.
Only 26.4% of opening questions were open‐ended ones in our data, compared to 67.2% in Heritage & Robinson's study (Table 1). 13 Moreover, confirming questions about symptoms accounted for 75.0% of closed‐ended ones, while Heritage & Robinson reported 48.5% (48/99). 13 These differences may stem from the existence and characteristics of the MQs. Before consultations in the US, a nurse usually uses a MQ to solicit problems from the patient and enters the information into the patient's medical chart. 13 The patient does not have access to how this information may be worded on the chart. In contrast, a MQ used in this study is filled out by a patient and handed over to the doctor via a medical assistant before consultation. Since the MQ is paper‐based, once the doctor brings it into the consultation, patient's descriptions on the MQ are available for both the doctor and the patient as an interactional resource in soliciting and presenting problems. Such use of the MQ is common in Japan. Since open‐ended questions imply that doctors are ignorant of patients' problems, the presupposition is inconsistent with the fact that doctors already have the MQs. Moreover, closed‐ended questions with sharing the MQs help to elicit patients' narratives which are not written on the MQs. These factors make it easier for doctors to choose closed‐ended questions as opening questions.
Our analysis showed that doctors treated the MQ differently depending on the type of opening question. In the open‐ended question cases, the difference between Extracts 1 and 2 was whether the doctor mentioned the MQ. The predominant verbal practice in cases with open‐ended questions was giving license to repeat the description from the MQ. The practice does not clearly indicate the relevance of the pre‐existing information on the MQ to problem solicitation. While open‐ended questions can encourage patients' narratives, the existence of the MQ may confuse patients about what to say due to recipient's design. Many doctors were aware of such probable confusion, and beforehand, this dilemma was resolved by the verbal practice to minimize the relevance of the MQ to problem solicitation.
In the closed‐ended question cases, doctors can also avoid such confusion as described above through the very question design that displays their knowledge from the MQ. However, closed‐ended questions are generally not recommended for use as opening questions, since they may inhibit patient's narrative by soliciting only yes/no answers. To cope with this dilemma, nonverbal practice of sharing the MQ not only showed the source of the doctor's knowledge but also highlighted his “limited access” to information about the patient's condition. 13 When a speaker mentions something the recipient is supposed to know better, the recipient is supposed to give additional information. Pomerantz has termed such a speaker's conversational attempt a “fishing.” 20 The difference between Extracts 3 and 4 was whether the doctor nonverbally shared the MQ with the patient. The nonverbal practice highlighted the relevance of the MQ to problem solicitation and succeeded to elicit patients' unexpressed narratives as a fishing device in cases with closed‐ended questions. Since open‐ and closed‐ended questions pose different dilemmas, doctors adjusted the level of relevance of the MQ to the context of problem solicitation.
Our study shed light on the importance of tailoring opening questions depending on the interactional context. Although open‐ended question is recommended, only its use is generally instructed to medical students in school curriculum. We elucidated that most of the doctors who performed that way were junior residents and more experienced doctors tended to add verbal or nonverbal practice to the opening questions. These suggested that doctors developed such practices not from undergraduate education but from their own experiences. With these practices, doctors display sensitivity toward building common ground in understanding patients. Such sensitivity develops patient‐centered care and can improve patients' health status. 21 It is expected that doctors' context‐dependent practices will be further elucidated and organized as communication skills for medical interviews. Video feedback is also useful to explore such careful practices.
5. LIMITATIONS
First, this study just focused on the utilization of the MQ for opening questions. However, there must be other ways to deal with the dilemmas that open‐ and closed‐ended questions pose as opening questions. In addition, it should be investigated how the combined use of multiple practices works. Second, selection bias for this study design is inevitable. In unrecorded consultations, patients may show confusion in different ways, and fewer doctors may deploy practices to avoid patients' probable confusion. Third, this study is based on data obtained from only a single department of a single university hospital in Japan. It should be explored whether the uses of MQs are different in other departments and other clinics/hospitals in Japan. Also, further investigation is needed to explore how doctors manage pre‐existing information about their patients in soliciting problems in other societies.
6. CONCLUSIONS
In this study, we have qualitatively and quantitatively identified doctors' practices for problem solicitation in first‐visit consultations in Japan. Since open‐ and closed‐ended questions pose different dilemmas as opening questions, doctors minimize the relevance of the MQ to problem solicitation in the former situation and highlight it instead in the latter. It will be useful to instruct such context‐dependent practices to improve communication skills in medical school curriculum.
ETHICAL APPROVAL
This study has been approved by the Ethics Committee of Kansai Medical University Hospital (Protocol Identification Number: 1516 [2015119]).
PATIENT CONSENT STATEMEWNT
All study participants agreed to participate in this study.
CLINICAL TRIAL REGISTRATION
None.
CONFLICT OF INTEREST
The authors have stated explicitly that there are no conflicts of interest in connection with this article.
ACKNOWLEDGMENTS
We would like to thank Silver Academic Editing (www.silverediting.com) for English language editing. This work was supported by JSPS KAKENHI Grant Number JP16K15312 and JP19K10523.
Abe T, Nishiyama J, Kushida S, Kawashima M, Oishi N, Ueda K. Tailored opening questions to the context of using medical questionnaires: Qualitative analysis in first‐visit consultations. J Gen Fam Med. 2023;24:79–86. 10.1002/jgf2.593
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